700414.pdfE
A
'ED ON KROLL MAP NO. PERMIT en r�%
NUMBER
SUILDING DEPARTMENT Applicant Fill
inside Heavy Lines JOB ADDRESS
PERMIT APPLI(
-BUSINESS)
NAMELOR�NAME-OF
i v YARD SETBACK
, SIDE. YARD SETBACK STREET SETBACK REAR
MA
ILING ADDRESS L
Z
USE ZONE LOT AREA
L/
Z
TELEPHONE VIJAIISZ� YES "b NO
�14 Y
HEIGHT BUILD A VARIANCE NUMBER
4
NAME
PLOT PLAN APPROVED
Vw�
ADDRESS
STREET R/W
TELEPHONE NUMBER EXISTING STREET R/W ............ FT. DEFICIENCY THIS PROPERTY
�CITY
............ FT.
COMP. PLAN ST. R/W ............ FT -
REMARKS
Lv A
CHECKED BY
-CITY TELEPHONE NUMBER
4 METER SIZE SERVICE SIZE CLEARANCE CHECKED BY
IATATE LICENSE NUMBER CITY LICENSE NUMBER
REMARKS
Four Copies)
t�Lcgal Description of Property (Show Below or Attach
TYPE CONNECTION
VERIFIED BY
Z s
Ir
PERO. TEST PERMIT NUMBER
REMARKS
FIRE TYPE OF CON STRUCTION
STREET IMPROVED
�ZONE I
YES NO
SPECIAL INSPECTOR REQUIRED
OCCUPANCY GROUP
YES NO
RESIDENTIAL
GAS
LINE
NEW
PLAN CHECKED BY
NON-RESIDENTIAL
El
SIGN
EJRETAINING
WALL
Iff ZMARKS
DEMOLISH
ALTER EXCAVATE
FENCE
OR FILL I .......... x .......... Ft.
REPAIR PRE -MOVE
El INSP.
swim
POOL
NUMBER OF STORIES NUMBER OF
DWELLING
UNITS
_ffA_TURE OF WORK TO BE DONE
Valuation
Fee
Receint
PROPOSED USE
PLOT PLAN (Indicate
�ulld,!n�� setbsc
I
itting streets)
t
N
I hereby acknowledge that I havo read this application; that the In-
formation given Is correct; and that I am the owner, or the duly author-
ized agent of the owner. I agree to comply with city and state laws regu-
lating Construction; and In doing the work authorized thereby, no person
will be employed In violation of the Labor Coda of the State of Washington
relating to Workmen's Compensation Insurance.
NOTE: Permit Limit One Year (Except DE51OLITIONS which
6411,b6 comple led In ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.)
IFG14ATUR-E (OWNER OR AGENT) DATE SIGNED
NOTE: Applicant Subject to Plan Check Fee
This Permit coven work to be -done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
marqueea,'etc.) will require separate permission.
Plan Check No.
BUILDING
PLUMBING
HEAT & GAS LINE
PENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR PILL
TOTAL AMOUNT DUE
ATMNT1014
TIUS PERMIT
AUTHORIZES
ONLY TILE
WORK NOTED
APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or his Dep-
uty;'and fees are paid, and receipt Is ac-
Imowledged in space provided.
INSPECTION DIRECTOR'S SIGNATURE
DEPARTMENT
CITY OF
DATE
EDMONDS
PH 0-1107
INSPECTOR
I
Drainage
Sewer
Parking
Landscaping
Fire Dept.